FEBRUARY 2015Volume 18Issue No. 2

PPS Alert for Long-Term Care

An Integrated Approach to the LTC Industry

As the government continues to encourage coordina-tion across the healthcare continuum, new research indicates that partnerships between nursing homes and hospices are picking up speed—and that these collabo-rations may yield manifold benefits for their patient populations.

“It’s so important to provide hospice services for in-dividuals in the place where they call home, and those folks in the nursing home, that’s their home,” says Peter Notarstefano, director of home and com-munity-based services at LeadingAge, a Washington, D.C.–based trade organization for nonprofit providers of aging services.

According to the 2014 edition of the hospice facts and figures report released annually by the National Hos-pice and Palliative Care Organization (NHPCO), the number of hospice patients who died in a nursing home rose from 17.2% to 17.9% between 2012 and 2013—the

New research points to perks of nursing home-hospice partnershipsHigh hospice penetration in the nursing home can reduce hospitalization risks for all residents and boost care coordination between settings

Medicare Advantage Q&A HCPro’s very own director of postacute education, Diane L. Brown, BA, CPRA, answers readers’ most pressing ques-tions about the contentious healthcare plans and providers.

Five reasons to identify a resident’s stage of dementiaIn this new column, dementia care expert Kim Warchol, OTR/L, DCCT, discusses the manifold benefits of identifying a resident’s specific stage of dementia.

Designing an effective QAPI programExcerpted from one of HCPro’s most popular books of 2014, this article pro-vides readers with applicable tips and specific examples to use when design-ing and determining the scope of your facility’s QAPI program.

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largest jump in any setting covered by the report.“As the average life span in the United States has

increased, so has the number of individuals who die of chronic progressive diseases that require longer and more sustained care. An increasing number of these in-dividuals reside in nursing homes prior to their death,” NHPCO states in its report. “This rise has been mir-rored by growth in the number of hospice patients who reside in nursing homes.”

As a result, there’s a growing coalition of inter-setting teams paving the way for significant improvements in patient outcomes, according to a recent study pub-lished in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA). Its findings suggest that a high hospice utilization rate (penetration) in a nursing home can reduce the risk of hospitalization for all of the facility’s residents—regardless of whether they are enrolled in end-of-life services.

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EDITORIAL ADVISORY BOARD

Diane L. Brown, BA, CPRADirector, Postacute EducationHCPro Danvers, Massachusetts

Sandra FitzlerSenior Director of Clinical ServicesAmerican Health Care Association Washington, D.C.

Bonnie G. Foster, RN, BSN, MEdLong-Term Care ConsultantColumbia, South Carolina

Julia Hopp, MS, RN, NEA-BCExecutive Vice President of ReimbursementParamount Health Care Company Garden Ridge, Texas

Steven B. Littlehale, MS, GCNS-BCExecutive Vice President, Chief Clinical Officer PointRight, Inc. Cambridge, Massachusetts

Mary C. Malone, JDHealthcare Attorney, DirectorHancock, Daniel, Johnson & Nagle, PC Richmond, Virginia

Maureen McCarthy, RN, BS, RAC-CT,President and CEOCeltic Consulting, LLC Farmington, Connecticut

Frosini Rubertino, RN, CPRA, CDONA/LTCExecutive Director Training in Motion, LLC Bella Vista, Arkansas

Holly F. Sox, RN, BSN, RAC-CTMDS CoordinatorPresbyterian Communities of South Carolina Lexington, South Carolina

Senior Director, ProductErin Callahanecallahan@hcpro.com

Product ManagerAdrienne Triversatrivers@hcpro.com

Associate Editor Delaney Rebernik drebernik@hcpro.com

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

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PPS Alert for Long-Term Care (ISSN: 1521-4990 [print]; 1937-7428 [online]) is published monthly by HCPro, a division of BLR®. Subscription rate: $269/year. • PPS Alert for Long-Term Care, 100 Winners Circle, Suite 300, Brentwood, TN 37027. • Copyright © 2015 HCPro, a division of BLR. • All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email customerservice@hcpro.com. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions ex pressed are not necessarily those of PPSA. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Key findingsThe study, entitled “The Effect of Hospice on Hos-

pitalizations of Nursing Home Residents,” examined whether residing in a nursing facility with higher hos-pice penetration reduces the risk of hospitalization for 1) hospice-enrolled residents when compared to their counterparts in facilities with lower hospice penetra-tion and 2) non-hospice residents.

Because a host of previous research had already linked hospice enrollment among nursing home residents with reduced hospitalization rates for these individuals, researchers developed the second prong of their hypothesis to explore additional, more indirect effects the presence of hospice in the setting can have on hospitalization risk, says Nan Tracy Zheng, PhD, research public health analyst at RTI International, a global independent, nonprofit institute based in Re-search Triangle Park, North Carolina, and lead author of the JAMDA study.

Using a sample of 505,081 non-hospice residents and 241,790 hospice-enrolled residents in 14,030 facilities across the country who died during 2005 to 2007,

researchers found that for every 10% increase in hos-pice penetration, the risk of hospitalization decreases 4.8% for hospice-enrolled residents (a phenomenon the researchers dubbed “the expertise effect”) and 5.1% for non-hospice residents (“the spillover effect”). To de-termine their hospice penetration variable, the authors of the study calculated the percentage of decedents per nursing home who received hospice care during the last 30 days of life, Zheng explains. Based on this criterion, the researchers found that U.S. nursing homes have an average hospice penetration of 28%.

Although determining whether the difference in magnitude between the spillover and expertise effects is significant fell outside the scope of the study, Zheng says the increased benefit of higher hospice penetration for non-hospice nursing home residents makes sense, as these individuals have a much higher baseline risk of hospitalization compared to their hospice-enrolled counterparts, a fact seemingly confirmed by another finding of the study: In the last 30 days of life, approxi-mately 37.6% of non-hospice residents are hospital-ized, compared to only 23.2% of their hospice-enrolled

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counterparts. Zheng notes that this latter statistic en-compasses all hospitalizations during the last 30 days of life for hospice residents, regardless of whether they occurred before or after enrollment.

In addition to highlighting a major benefit of hos-pice for enrolled residents, the spillover and expertise effects demonstrate the more far-reaching implications of hospice in the nursing home setting. The reduced risks for hospitalization that occur across the board as hospice penetration increases suggests that simply heightening the exposure of nursing home staff to pal-liative care practices may influence the confidence and aptitude with which these professionals care for resi-dents during their final days, regardless of their deci-sion about hospice election, Zheng explains.

“There is something about this collaboration that might help nursing home staff improve their compe-tencies and have a better understanding of skills for end-of-life care,” she says, adding that boosted expo-sure can also strengthen coordination and communica-tion between hospice and nursing home staffs.

Benefits of reducing hospitalization risksThe findings of the JAMDA study are particularly

important because of the significant and diverse costs associated with the hospitalization of nursing home residents at the end of life.

Hospital stays during this difficult time can severely jeopardize a resident’s well-being on multiple fronts, Zheng explains. They can incite adverse clinical out-comes, including infection, irreversible functional decline, and new or worsened pressure ulcers, while the implications of relocating can place extra physical and emotional stress on already vulnerable individuals. In addition, the move can disrupt execution of the care plan, defy a resident’s wishes or beliefs, and place more financial strain on the individual and his or her family.

But increased hospice penetration in nursing homes can diminish these harmful side effects by shrinking hospitalization risks. “Overall, the evidence shows that there are opportunities for improved quality of care and quality of life for end-of-life residents by reducing hospitalizations at the end of life,” Zheng explains.

In addition to presenting new possibilities for im-proving residents’ well-being during their final days, reducing hospitalization risks by partnering with

hospice providers can be cost-neutral for nursing homes, or even generate savings in some cases, such as when the decreased risk stems from earlier identifica-tion and management of an individual’s symptoms, Zheng explains. However, she notes that nursing homes may incur some additional costs in cases where the decreased risk results from the provider learning to manage conditions that would have previously com-pelled it to hospitalize a resident.

But in either scenario, Zheng stresses that nursing homes’ conscious effort to lower hospitalization rates among residents by teaming with hospice providers may result in significant societal savings by alleviating the heavy financial, health, and emotional expenditures associated with hospital stays.

In addition, although the JAMDA study only ex-plored the impact of hospice penetration on hospi-talization risk among nursing home residents, Zheng points to a large body of research that highlights hos-pice penetration’s association with more effective pain management, better care processes (e.g., lower rates of physical restraint usage and potentially inappropri-ate feeding tubes), and higher family satisfaction rates in the nursing home community. Zheng says this last component might be due to the heightened emotional attention and support hospices often offer to beneficia-ries and their families.

But nursing home cultures aren’t the only things that benefit from high hospice penetration, according to Notarstefano, who calls inter-setting collaborations “a win-win for both providers.” He explains that while nursing home staffs learn more specific strategies and philosophies for providing effective end-of-life care, hospice personnel likewise gain important insight about how to provide holistic care for individuals with multiple conditions and comorbidities. He adds that the two entities are particularly well-suited for teaming up because both have been evolving over the years to care for advanced illnesses that would have previously landed a patient in a hospital.

Forging successful partnershipsFrank Russo, vice president of risk management

and privacy officer of Silverado Care, a postacute care agency based in Irvine, California, says that partner-ships between nursing homes and hospices can flourish

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when the two providers share similar attitudes toward care and place trust in one another—both of which facilitate the inter-setting team’s delivery of seamless care to the patient.

“We want the patient not to be disrupted whatso-ever and get the care that’s necessary to them,” Russo says, explaining that this coordination of care delivery across settings is an especially high priority for Sil-verado because of the three distinct services it provides: homecare, hospice care, and memory care. This final offering takes the form of assisted living communities whose methods and types of care are often comparable to nursing home settings, he adds.

Despite the centrality of shared values and trust to effective partnerships, Russo also points to the impor-tance of ensuring that pivotal operational resources for hospices and nursing homes (e.g., staffing and training) don’t bleed into one another, especially for organiza-tions that offer both services.

“[Hospice] is very unique in both its challenges and requirements compared to an assisted living or a nurs-ing home setting,” Russo explains, warning providers against foraying into hospice without the specific exper-tise, policies, and education it requires. “For providers offering both services like us, ensure that service lines operate in a collaborative environment ... [but don’t] attempt to manage co-joined resources.”

To strike this delicate balance between independence and teamwork, Silverado coordinates regular care meetings between its hospice and memory care enti-ties to discuss the needs of residents who are enrolled in both services and to share any pertinent documents and information, Russo explains. Silverado also at-tempts to coordinate care with the outside hospice providers with which its residents elect care, though the organization experiences less consistent success on this front, Russo adds. He explains that without the shared requirements, protocols, and reporting thresholds in-herent in being run by a single company, collaboration between two disparate settings takes more willpower.

“Challenges … usually stem from communication, coordination, ensuring the plan of care is communi-cated by both sides, and medication delivery is appro-priate,” he says.

Notarstefano agrees that these are make-or-break areas, and advises providers pursing partnerships to

focus on improving them. In particular, he empha-sizes the importance of creating an effective, custom-ized care plan by consulting all affected parties: the nursing home and the hospice, as well as the resident and his or her family. This means that residents should understand and approve of their care plans and that all healthcare providers should honor their contents. In addition, Notarstefano says the respect for a patient’s specific needs and desires should permeate all departments and practices within an organization—including marketing. For example, he explains that hospices should exercise ethical mar-keting strategies by providing nursing homes and prospective patients with transparent and easily ac-cessible tools, resources, and information to under-stand eligibility criteria.

The advice of both Russo and Notarstefano is backed by long-standing research. Zheng points to a report NHPCO published in 2007 that studied six nursing home–hospice collaborators to determine practices that can foster successful inter-setting partnerships. In addition to highlighting the importance of developing systematic processes to promote consistent commu-nication between settings and sharing similar philoso-phies of care, the report listed some specific “collabora-tive solutions,” including:• Open acknowledgement by nursing homes that

death occurs in the setting and the consequent es-tablishment of practices that provide special sup-port to dying residents and their families

• Implementation of mechanisms to facilitate regular assessment of the partnership

• Use of joint education to address relationship building and conflict resolution, as well as the care aspects, regulations, and environmental factors that are unique to each provider

• Facilitation of regular dialogues between the CEOs of both providers

• Prompt response by the hospice to requests made by the nursing home and purposeful structuring of hospice visits

• Expedient Medicare per diem payment by nursing homes (even when state Medicaid payment is slow) and 100% per diem payment by hospices

• The offering of support by hospices to nursing homes during key operational processes, such

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as surveys, Medicaid applications, and hospice resident follow-ups

The legislative element Although these strategies can help providers over-

come day-to-day partnership challenges posed by nego-tiating the unique cultures, values, and motivations of disparate settings, Notarstefano says the significant flaws in the payment structures that underlie today’s healthcare systems are much more encompassing bar-riers to effective collaboration. He believes that current reimbursement models—which were implemented when providers worked in unchallenged silos—incen-tivize increasing profit margins more than improving patient outcomes.

“It’s not the hospice-nursing home partnership that’s the problem. … It’s the payment system that I think is broken,” he says.

But Notarstefano also acknowledges that the pitfalls of today’s payment structures have not gone unnoticed

by the government, which has been working to get long-standing regulations up to speed with evolving attitudes toward care and coordination throughout healthcare. He points to recent legislative pushes for standardized quality measures across settings, as well as the continued development of accountable care organizations and bundled payment models. He hopes that Congress continues to introduce similarly produc-tive legislation by translating important research find-ings about best practices—like those presented by the JAMDA study—into policy that furthers today’s focus on reforming payment structures, advancing health-care standards, and improving patient outcomes across settings.

“Congress has passed legislation that has really broken down some silos, ... [so] we’ll be able to com-pare .... what’s working and what’s not working and what’s really improving the quality of life for individu-als,” he explains. “We’re comparing apples with apples, and in the past we weren’t able to do that.” H

Medicare Advantage Q&A

Medicare Advantage plans, also known as man-aged care, Part C, and MA plans, are offered by Medicare Advantage Organizations (MAO), which are private companies that contract with Medicare to provide beneficiaries with Part A and Part B services. These health plans—which include health mainte-nance organizations, preferred provider organiza-tions, private fee-for-service plans, special needs plans, and Medicare medical savings account plans—are girded by a complex web of regulations, and as they continue to gain a stronger foothold in long-term care, they’ve become increasing pain points for some in the SNF community, who have criticized MAOs for communication lapses and onerous billing practices.

To help providers navigate the evolving Medicare Advantage landscape, HCPro asked long-term care readers to share their most pressing questions, con-cerns, and challenges in this arena. We compiled a list of your responses and recruited our resident director

of postacute education, Diane L. Brown, BA, CPRA, to shed some light.

If you have additional questions or feedback regard-ing Medicare Advantage or any other long-term care topic, please email Associate Editor Delaney Rebernik at drebernik@hcpro.com.

Q We have chronic problems with delayed discharg-es from Care Improvement Plus [an MA special

needs plan] because of their pre-certification system. They require initial PT [physical therapy] and OT [oc-

cupational therapy] assessments before they will initiate a precertification for acute rehab or NH [nursing home], and then they have a 48-hour turnaround time for mak-ing a decision.

We had a patient that was admitted on Monday with acute CVA [cerebral vascular accident], needing all three disciplines. We requested acute rehab, they denied acute rehab, and then I had to initiate another precertifi-cation for NH, waiting another 48 hours.